Documentaion Legality and Etiquette

  1. I am confronted with a situation and would like some input from the "Virtual Community". I am under the belief that when we do our charting we are to chart what WE do. Period ! I am also under the belief that we do not put other nurses full and legal names in the charting. Examples: I DO chart "Foley 16F30cc reinserted without difficulty. 100cc of lt amber urine noted with foley insertion. Pt tolerated proccedure well." I would not chart " Stna reported to me foley out. Told 3-11 nurse Suzy Washington LPN to reinsert it." The is a fabricated scenario and the proceedure was far more serious. It was the reinsertion of a trach. The RN supervior who elected to put a new trach in, after the old one was found out. There is no order in chart that says Trach to be reinserted by staff. Prior dislodgements have resulted in Pt being sent to ER. (We are at a LTC facility, no house MD, no Resp. Therapy, just LPN charge nurses and occasional RN supervisor) I had discussion with the supervisor who charted pulse ox to be performed q 15 min by (me) Full Name. This was as a follow up intervention . I was told that to protect his license he had every right to document whatever direct order( verbal) he gave any LPN, and it was their problem and License that was in trouble if they did not do it. Yet when I asked if it was appropriate to chart "Paged supervisor Joe Supernurse, RN to floor at 10am , no response. Rn supervisor paged to floor 10:05am, no response, supervisor Joe Supernurse, Rn paged to floor stat", he said no, that would make him look bad, took the nurses notes and made his note before I could chronologialy chart , not with the blaming, just straight forward charting,what happened. I told him numerous times I think we should call 911 and send the PT out as has been done before. I also know that the proceedure was done incorrectly by him, with many errors.He is fond of telling everyone how he was a Paramedic before becoming an RN and they are was more skilled than any RN he has met. The dynamics of Paramedic charting may vary from nursing, but I know nothing about their Regs. I do know he is working at the LTC under the license and capapcity as an RN, not a Paramedic. So help me out here, smart ones! I think the MD should of been notified and subsequent orders recieved. The supervisor insits that I am working under his RN license and must do what ever he tells me. I think hiding things in the charting and hoping someone stumbles accross them to chart to protect their license is poor practice. I think charting what someone else is supposed to do does not relieve you of the responsiblity of doing it.I have seached extensively for something to back me up on these ideas I have and can't find anything to support it, yet all my long time Nurse friends agree. Am I off base here? There seems to be many things wrong with the entire situation and I would like something to validate my concerns.
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  2. 9 Comments

  3. by   pricklypear
    I'm sure you'll get some really great answers to this. Personally, I don't think you're off base at all. His actions sound wrong all the way around. No, you do not work under his license. You work under your own. If you do "whatever" he tells you, right or wrong, it's YOUR license, not his.
  4. by   control
    I use names in my charting, not always the full legal name though. When I do do this, I chart what has been done in the case of procedures, tasks, and activities. However, especially when dealing with physicians, sometimes I will document what they've said to me verbatim and the doctor's name.

    I have no problem with someone charting "IV was restarted to the right dorsal forearm by Control Nurse, RN after 2 attempts." However, I would have a problem with someone charting "Control RN said she would attempt the IV." and leave it at that.

    HOWEVER....Every nurse should take it upon him/herself to cover their own behinds and chart what he/she did, I think.
  5. by   AuntieRN
    I am only a student so perhaps charting is a little different for us, but I know we are told to chart something like this...reported pain 8/10 to S. Nurse, RN. S. Nurse, RN gave pt. morphine 4mg IVP. We have always been taught up until this point to only chart what we our ownselves have done. Not what anyone else told us to do. Unless it was a doctor who came into the room while you were there alone with the patient. then you would chart what the doctor told you to do, which I also do not understand because wouldn't this be considered a verbal order? And I know definately as a student we do not take verbal orders, and it was my understanding most hospitals do not allow verbal orders anymore anyways. Charting is almost as confusing as care plans are to me. Hope I get it all down some day.
  6. by   mopsi
    Being a student is great. It may give a more current perspective. Are you taught to chart what you do? Not what you want someone else later to perhaps do. Are being taught to put in initials when refering to another staff member , not their full name? Are you being taught that an RN gives verbal orders to an Lpn and must be followed? Are you being taught that when something serious or irregular happens you contact the doctor before doing your own thing? I have been an LPN for 15 years and have returned to school to get my RN, so it's not like I have limited experience with scope of practice. I am truely puzzled by myself and another nurse having such a vast difference on what to chart and how to chart. I can not find any resources stating what I have adopted as a standard, not putting in someones name and not charting what someone is supposed to do, is correct. I am also puzzzled by the statement that an RN gives orders to an LPN and they better be followed, or my license is endangered. I can not find anything other than a LPN is under the direction of an RN, which is a little different than taking orders as from an MD. In 15 years I have never had a conflict even remotely like this so I am really at a loss here. I hope someone with some experience can give a little input here. I would be delighted if you posed this situation to your instructors and got back with their feedback. Thanks So Much!
  7. by   CoffeeRTC
    Sounds like the DON needs to be invoved.
  8. by   gypsyatheart
    Ditto. And quick. I would be equally concerned that this nurse may be performing outside of his scope of practice. The MD should've been notified as well. Remember, we are here to advocate for our patients, and if you know the procedure was performed incorrectly, he needs to be called on it. If not by you then by his supervisor.

    Good luck!


    Quote from michelle126
    Sounds like the DON needs to be invoved.
  9. by   nurse_ange1
    I work on a surgical floor where we have fresh trach patients. As an RN (and a new one at that), it is my responsiblity to know which type of trach is required and whether or not it deflated or not. Also, an extra trach must be at the bedside along with all of the other suctioning equipment. In such a case were a trach would be dislodged, I reinsert the appropriate size trach immediately and then call the doctor stat, and then monitor the patient very carefully.

    Could the persons air way not be comprimised resulting in respirator arrest if you waited until the abulance arrived and did nothing to keep the air way open? I think the RN is correct in inserting it but WAY off in not notified the doctor.

    Also, if documenting that some else did the care such as starting an IV that I was unsuccessful in starting, I write first name with last name Initial and their title.Also, I don't believe it appropriate to document care which has yet to happen such as Name RN to monitor saturation for 15minutes. I would document that saturation will be monitored. Then after the 15 minutes or less, I would document that the sat has been monitored and remains above ??% along with a full set of vitals and any other important s/s of distress or improvement. I would also be documenting my attempts to contact the MD or on call MD.
  10. by   fergus51
    IMO there is nothing wrong with charting attempts to contact anyone (doc, house sup, whoever) and nothing wrong with charting instructions given to someone under your supervision (LPN, CNA, etc). Think about it, if this becomes a court case in 2 years will the RN be able to remember who was told what? Probably not if it isn't charted. Then what is the RN supposed to say? "Ummmm... I'm sure I told someone to monitor the pt's sats, I just can't remember who".

    As far as not contacting the MD, that is crazy. The DON should be involved.
  11. by   CMG85
    I too am a first year nursing student... Documentation is something we are going over now...The delegation of tasks to LPNs is acceptable but not in the manner this particular RN did it... Why? Because no procedure should be documented unless performed. e.g: BP q30min( This should be documented after each succesive 30 min along with the results.) Sounds to me like this person is abusing the his authority to delegate tasks....Something he should be doing he's making you personally responsible...Not right at all...

    Hopefully i didn't just restate what everyone has already said..

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